Current state of diagnostic management of acute vertigo: a survey of neurologists in Germany.

Abstract

Dear Sirs, Acute vertigo belongs to the most frequent symptoms in emergency rooms and in general neurology. The differentiation between peripheral and central causes is crucial, yet most neurologists are uncertain in deciding which diagnostic techniques they should rely on. Current care for many patients with acute vertigo is both inaccurate and expensive [1]. Improving diagnostic accuracy would have important clinical and economic consequences, including rapid stroke diagnosis and reducing unnecessary testing, particularly neuroimaging [2]. In recent years, several new techniques have been introduced in clinical practice that helps to differentiate acute central from peripheral vertigo [3]. This study aimed to address the current state of diagnostic management in patients with acute vertigo by neurologists in Germany. The internet-based survey comprised a questionnaire of standardized questions (see Supplemental data), e.g., individual evaluation of the meaning of clinical tests, and selfconfidence in one’s own diagnostic correctness. The questionnaire was distributed to all members of the German Neurological Society (DGN). 362 German neurologists participated in this study (4.8 % of 7,581 members). The majority of participants (61.2 %) had passed the Neurological Board Examination (specialists) and had long-standing neurological experience (15.5 ± 0.6 years). 31.3 % of all participants were residents with a mean of 3.7 ± 0.3 years of neurological experience. Participants rated patient’s history and the clinical examination as the most important criteria to differentiate peripheral from central vestibular lesions (Fig. 1a). Cranial MRI was the third important factor, while neuro-otological tests played a minor role. The meaning of patient’s individual history was significantly more important for specialists in neurology than for residents. Residents, in contrast, relied significantly more on brain imaging results. Participants rated the meaning of a pathological head impulse test (HIT) and the absence of additional neurological signs higher in diagnosing peripheral vestibular vertigo than the presence of horizontal-torsional spontaneous nystagmus or vertical skew deviation (Fig. 1b). HIT is clinically used by 96.3 % of all participants. In contrast, only 14.6 % administer techniques to quantify HIT. About 2/3 of all do not rely on their own HIT without additional brain imaging investigations (Fig. 1c). Specialists rely more frequently on the clinical HIT than residents. Except for caloric irrigation, additional neuro-otological tests play Electronic supplementary material The online version of this article (doi:10.1007/s00415-014-7405-9) contains supplementary material, which is available to authorized users.